Some Uncomplicated STEMI Patients May Not Need ICU Care

Debra L. Beck

April 15, 2019

More than 80% of stable patients with uncomplicated ST-segment elevation myocardial infarction (STEMI) are treated in intensive care units (ICUs), a new retrospective registry study shows, but the risk of developing a complication requiring ICU attention in this cohort is only 16.2%.

Researchers found the complication rate dropped to 13.4% for patients with first-medical-contact (FMC)-to-device time of less than 60 minutes. In those treated in 61 to 90 minutes or more than 90 minutes, complications were seen in 15.7% and 18.7%, respectively (for trend < .001).

"I think what is novel about our study is the finding that the risk of having a complication among this group of stable, older STEMI patients is 16%, and that we've confirmed what we suspected intuitively, which is that if we treat patients faster, the risk of developing a complication is lower," said lead author Jay S. Shavadia, MD, Duke Clinical Research Institute, Durham, North Carolina.

"But even for those who were reperfused quickly, 13% is really not a small number, so while we are saying that we may be overutilizing ICUs in STEMI, even in people who are quickly treated there is a sizable subgroup of people who are stable when they first come in, but still have a sizable risk of developing a complication that will require intensive care," he added.

The study was published online on April 15 in JACC: Cardiovascular Interventions, and will appear in the April 22 print issue.

The researchers used data from the National Cardiovascular Data Registry Chest Pain-MI Registry, a large, ongoing quality-improvement initiative sponsored by the American College of Cardiology.

They linked registry data to Medicare claims for patients 65 years and older who had uncomplicated STEMI at initial presentation and no compelling indications for ICU or coronary care unit (CCU) care, including no signs of heart failure or shock at presentation.

The analysis population consisted of 19,506 hemodynamically stable patients who underwent uncomplicated primary PCI at 707 hospitals in the United States.

Treatment in the ICU was defined as having a revenue code for ICU or CCU during the index hospitalization. Median ICU stay was 1 day.

In-hospital complications potentially requiring an ICU stay included death, cardiac arrest, postadmission shock (cardiogenic and not), stroke, high-grade atrioventricular block requiring treatment, and postadmission respiratory failure of all forms.

Interestingly, ICU utilization did not differ among patients who were perfused early, intermediate, or late after first medical contact: the rates were 82%, 83%, and 82%, respectively.

"It wasn't surprising that 82.3% of these patients overall were admitted to the ICU after primary PCI because that is how we've been practicing and there is justified reluctance to not send a patient to the ICU after STEMI, just because we don't know which patients will complicate," said Shavadia.

"We should be cautious about making an overarching statement about overutilizing the ICU or CCU, because we don't yet have a good model to predict these people who will develop a complication are," added Shavadia.

Shavadia was a research fellow at the Duke Clinical Research Institute when this study was completed, but is now at the University of Saskatchewan in Saskatoon, Canada.

Of patients not sent to the ICU after revascularization, the complication rate was 7.8%. In an interview, Shavadia explained that this is a hard group to comment on because the Chest Pain-MI Registry did not capture the reason or reasons why they were not admitted to the ICU, "so it's hard to make any definitive statement about their risk of developing a complication."

Potential cost savings were not explored, but Shavadia noted that they could be expected to be substantial, "if we can develop a model that predicts who is really low risk and doesn't need the ICU, but rather can be sent to a ward setting or telemetry bed."

Indeed, that is what editorialists Suartcha Prueksaritanond, MD, and Ahmed Abdel-Latif, MD, PhD, University of Kentucky, Lexington, are trying to do.

In an interview, Abdel-Latif said that his group is currently testing an algorithm in their hospital that considers six or seven factors to identify patients who likely can be sent from the cath lab to a telemetry bed and skip the ICU.

He said that at his institution, a telemetry bed is about 40% of the cost of an ICU bed, including nursing care, tests performed, and other resources used.

As for the Shavadia study, Abdel-Latif said, "this concept that not everyone needs to be treated like they were 10 years ago is gaining traction in the field now and this study adds another piece of information to that bigger puzzle."

In this current study, only about 28% of the patients they have enrolled to date are 65 years and older.

"The study by Shavadia identified first medical contact as an important factor and other studies have seen that other factors are important, like blood pressure on arrival to the hospital, or the degree of heart failure on arrival," said Abdel-Latif.

"We are at a point now in the field where we have a growing body of evidence and we need a big randomized trial that will incorporate the information we have to inform the design and create a way of identifying who is truly at risk and in need of ICU monitoring," he added

Shavadia and Abdel-Latif reported no conflicts of interest.

JACC: Cardiovascular Interventions. 2019;12:709-17. Abstract, Editorial

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